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Management of Patients Undergoing Endoscopic Procedure - Adult - Ambulatory Consensus Care Guideline

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Management of Patients Undergoing Endoscopic Procedure - Adult - Ambulatory Consensus Care Guideline Effective 01/29/2020. Contact [email protected] for previous versions. Suspected or Confirmed Heart Block: Management of Patients Undergoing Endoscopic Procedure - Adult - Ambulatory Consensus Care Guideline Note: Active Table of Contents – Click to follow link EXECUTIVE SUMMARY ....................................................................................................................................... 3 SCOPE ................................................................................................................................................................ 3 METHODOLOGY ................................................................................................................................................. 4 DEFINITIONS ...................................................................................................................................................... 4 INTRODUCTION.................................................................................................................................................. 5 RECOMMENDATIONS ......................................................................................................................................... 5 UW HEALTH IMPLEMENTATION ......................................................................................................................... 7 APPENDIX A. EVIDENCE GRADING SCHEME(S) .................................................................................................... 8 APPENDIX B. DIGESTIVE HEALTH CENTER ENDOSCOPY PATIENTS HEART BLOCK ALGORITHM .............................. 9 REFERENCES ...................................................................................................................................................... 10 1 Copyright © 2020 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: [email protected] Vermeulen, [email protected] Last Revised: 01/2020 Effective 01/29/2020. Contact [email protected] for previous versions. Contact for Content: Name: Deepak Gopal, MD - Gastroenterology Phone Number: (608) 263-7322 Email Address: [email protected] Contact for Changes: Center for Clinical Knowledge Management Email: [email protected] Coordinating Team Members: Anne O’Connor, MD- Medicine- Cardiology Joel Johnson, MD- Anesthesiology Jeffrey Lee, MD- Anesthesiology Katherine Le, PharmD- Center for Clinical Knowledge Management (CCKM) Review Individuals/Bodies: Carin Endres, PharmD- Drug Policy Committee Approvals/Dates: DHC Executive Committee (03/01/2017) Clinical Knowledge Management (CKM) Council (Last Periodic Review: 01/23/2020) 2 Copyright © 2020 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: [email protected] Vermeulen, [email protected] Last Revised: 01/2020 Effective 01/29/2020. Contact [email protected] for previous versions. Executive Summary Guideline Overview This guideline was developed to assist clinicians in determining whether or not to perform an endoscopic procedure for a patient with a newly suspected atrioventricular (AV) block. Key Practice Recommendations 1. If a patient is diagnosed with a 1st degree AV block or 2nd degree type I AV block and is hemodynamically stable, the endoscopic procedure may be performed. A first-degree heart block is typically not an indication for hospital admission and no specific treatment is generally required.1 A second degree type I AV block usually has a benign cause and treatment is unnecessary in most cases as well.2 (UW Health GRADE Very low quality of evidence, weak/conditional recommendation) 2. If the patient is diagnosed with a 2nd degree type II AV block or 3rd degree AV block, it is recommended to cancel the procedure and treat as clinically indicated. (UW Health GRADE Very low quality of evidence, weak/conditional recommendation) 3. If the AV block occurs during a procedure and resolves spontaneously within seconds or minutes, the physician may consider completing the procedure. (UW Health GRADE Very low quality of evidence, weak/conditional recommendation) 4. If the AV block occurs as a narrow QRS complex or prolonged PR interval with significant decreased in blood pressure or heart rate, the provider may consider giving atropine as it reduces AV block due to hypervagotonia.3,4 (UW Health GRADE Low quality of evidence, weak/conditional recommendation) 5. If AV block occurs more than once after initial resolution, consider aborting the procedure. (UW Health GRADE Very low quality of evidence, strong recommendation) 6. If AV block occurs as multiple P waves in a row or a wide QRS complex, consider aborting the procedure as these are indications that a 2nd degree type II AV block or worse is occurring. (UW Health GRADE Moderate quality of evidence, strong recommendation) Companion Documents Adult Endoscopy Patients Heart Block Algorithm Scope Disease/Condition(s): Heart block Clinical Specialty: Gastroenterology, Cardiology, Anesthesiology Intended Users: Physicians, Advanced Practice Providers, Nurses Objective(s): To determine if an endoscopic procedure should be done in a patient with a new AV block who do not have a pacemaker Target Population: Adult patients who present to the Digestive Health Center or Ambulatory Procedure Center for an endoscopic procedure with a suspected new AV block based off of pre- procedural bedside monitoring. Interventions and Practices Considered: 1. Cancellation of the procedure 2. Pharmacotherapy for heart block 3 Copyright © 2020 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: [email protected] Vermeulen, [email protected] Last Revised: 01/2020 Effective 01/29/2020. Contact [email protected] for previous versions. Major Outcomes Considered: 1. None identified Methodology Methods Used to Collect/Select the Evidence: Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and workgroup members to collect evidence for review. Expert opinion and clinical experience were also considered during discussions of the evidence. Methods Used to Formulate the Recommendations: The workgroup members agreed to adopt recommendations developed by external organizations and/or arrived at a consensus through discussion of the literature and expert experience. All recommendations endorsed or developed by the guideline workgroup were reviewed and approved by other stakeholders or committees (as appropriate). Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations: Recommendations developed by external organizations maintained the evidence grade assigned within the original source document and were adopted for use at UW Health. Internally developed recommendations, or those adopted from external sources without an assigned evidence grade, were evaluated by the guideline workgroup using an algorithm adapted from the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology (see Figure 1 in Appendix A). Rating Scheme for the Strength of the Evidence/Recommendations: See Appendix A for the rating scheme(s) used within this document. Recognition of Potential Health Care Disparities: None identified. Definitions First Degree AV block is a prolongation of the PR interval on an electrocardiogram (ECG). In a first-degree AV block, each P wave is followed by a QRS complex with a PR interval that exceeds 200 milliseconds.5 Second Degree Type I AV block or Mobitz type I AV block occurs when conduction of the atrial impulses to the ventricles is intermittently blocked. It is characterized by a progressive increase in PR interval prior to a blocked non conducted beat/QRS complex. After the dropped QRS, AV conduction recovers resulting in a normal PR interval and a progressive increase in PR interval begins again.1 Second Degree AV block Type II or Mobitz type II AV block is due to intermittent failure of conduction of atrial impulses to the ventricles. It is characterized by fixed PR intervals before and after blocked beats and may be associated with a wide QPRS morphology.6 Advanced second-degree block is the block of two or more consecutive P waves.1 Third Degree AV block happens when there is no conduction of impulses from the atria to the ventricles.5 4 Copyright © 2020 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: [email protected] Vermeulen, [email protected] Last Revised: 01/2020 Effective 01/29/2020. Contact [email protected] for previous versions. Introduction Atrioventricular blocks are a disruption in the conduction of the atrial impulse to the heart ventricle. Transient AV block can occur in about 4% of women and 6% of men. This number decreases in the normal older adult population, with Type I second degree AV block observed in about 1% of the population.7 Vagally mediated AV block can occur in otherwise healthy individuals and is generally benign, however it should be differentiated from true type II Mobitz block which requires immediate medical attention.1 Given the vagus nerve’s relationship to the abdomen and parasympathetic nervous system and sedatives’ effect on the respiratory system, it is critical to be attentive to any suspected heart block in a patient undergoing a digestive health procedure. This guideline is meant to aid clinicians in determining how to proceed in a patient undergoing an endoscopic procedure with a newly suspected heart
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